ASSESSMENT PADIS

Question 1

GENERAL APPROACH TO ASSESSING
THE TOXICOLOGY PATIENT

Answer 1

n Airway
n Breathing
n Circulation
n Decontamination
n Elimination
n Find an antidote
n General management
n History and physical

Question 2

The Toxic Emergency
Components of Assessment

Answer 2

STABILIZATION (ABC’S)
HISTORY PHYSICAL EXAMINATION DIAGNOSTIC TESTS

see slide 4

Question 3

STABILIZATION

Answer 3

n Never forget the ABC’s
n The cause of the symptoms doesn’t change
the approach to stabilizing the patient
n Assess adequacy of airway and ventilation
n Assess cardiovascular system
n Assess mental status or level of
consciousness (GCS)

The cause of poisoning is SECONDARY to stabilization

Question 4

ABC’S

Answer 4

n Airway
n Foreign body?
n What color is the patient?
n Breathing
n Can you hear choking, gagging, stridor or wheezing?
n What about speech - full sentences, slurred speech?
n Circulation
n Lethargy? dizzy? skin color?
n If patient described as “passed out”, “dopey”, “spaced
out”, or “out of it” what does that mean?

Question 5

HISTORY

Answer 5

n After stabilization complete
n Goals:
n To obtain further information about patient and
the situation
n To determine if exposure is toxic vs non toxic
n To obtain the information needed to make your
final assessment and plan for care

Question 6

HISTORY- Toxic vs Nontoxic

Answer 6

n General concepts:
n Is the history consistent with the presenting
symptoms? (Does the poison match the patient
presentation?)
n Keep a high index of suspicion if symptoms don’t
“fit”
n Consider an alternate toxin or differential
diagnosis (medical condition)

Question 7

HISTORY – Common Problems

Answer 7

n History often unreliable or absent (eg
patient found unconscious)
n Patient may not know, or may not be able to
verbalize what they ingested
n Patients may not want to volunteer what
they ingested
n Ask family, friends, paramedics or bystanders if
any additional history available

Question 8

HISTORY – Things to Consider

Answer 8

n Was this a witnessed exposure?
n Family, paramedics, bystanders, friends
n Ask them to go over history with you
n Where the patient was, what they were doing, and what
happened
n Past medical/psychiatric history
n Medications (Use Netcare where appropriate to
know “what cards are in the deck”)
n History of illicit drug use

n Circumstances
n Work/hobbies
n Preceding symptoms
n Any one else ill?
n Pregnancy

Question 9

HISTORY - Paramedic

Answer 9

n Paramedics at the scene often gather up all
the bottles in the area
n May need to sort out which they’ve actually taken
n Paramedics may be only people to speak
with first hand witnesses
n May be helpful to get them to go over what
THEY saw on scene
n Who called EMS?

Question 10

What did this person take?
The 10 Ps of Poison History taking

Answer 10

n 1) Check Pockets
n 2) Ask the Patient
(Duh!)
n 3) Ask
Parents/Partners/Pals
n 4) Prehospital
personnel (EMS)
n 5) PADIS
n 6) Pedestrians
(Probably Low yield)
n 7) Police
n 8) Personal MD
n 9) Past History (old
chart)
n 10) Pharmacy

Question 11

Physical Exam

Answer 11

n Head to toe approach
n Mental status,
behaviour
n Vital signs including
temperature
n Respiration quality
n Skin
n Pupils
n Bowel sounds
n Muscle tone
n Reflexes
n Odors - less frequent
n Secretions

LOC, behaviours
Vital signs most often necessary to diagnose a toxidrome
Pupils give high yield
Same with skin

Question 12

ASSESSMENT - ORAL/PARENTERAL EXPSOURE

Answer 12

n Review systems
n CNS
n CVS
n Respiratory
n GI/GU

n Don’t forget
n Pupils
n Odors
n Temp
n Muscle Activity
n Skin appearance/feel

Question 13

ASSESSMENT - DERMAL
EXPOSURE

Answer 13

n What does the skin look like?
n Red, irritated, blistered, swollen, blue or grey?
n What does patient describe skin as feeling like?
n Painful or Itchy?
n Has skin been irrigated? What was the result?
n What other treatments has patient already
done?
n Have they put any creams/ointment on?
n Did they attempt to “neutralize” agent?

Question 14

ASSESSMENT - EYE EXPOSURE

Answer 14

n Can the patient open the eye?
n Is it red or swollen?
n Tearing or other purulent drainage
n pH, eye exam
n Foreign body sensation
n Visual acuity
n Photophobia
n Has eye been irrigated? What was the result?

Question 15

ASSESSMENT - INHALATIONAL
EXPOSURE

Answer 15

n ABC’s important here
n Has the patient had fresh air?
n Coughing/choking
n Audible wheezing or stridor
n Able to speak full sentences?
n Was patient wearing any protective equipment?
e.g. respirator
n What about rescuers? Were they exposed? e.g.
H2S?

Question 16

GLASCOW COMA SCALE

Answer 16

eye opening
motor response
verbal response

Out of 15
Lowest score is 3
Highest is 15

Intubated pt scored out of 10
Not validated in context of poisonings
As GCS goes down, less likely to protect airway

Less than 8 intubate for head injury - can use as ref for poisoning

Question 17

LABORATORY and DIAGNOSTICS

Don’t just order a test without a rationale for
that test
n Example: If the poison in question doesn’t impact
blood count, don’t recommend a CBC.
n You need to be prepared to do something
about the results of that test. (Own IT!)
n Consider the impact on:
n Health Care System AND Patient

Answer 17

n Can be used to identify or confirm toxin
n Assess degree of toxicity and patient’s need for
treatment
n Common chemistry tests which PADIS
frequently considers:
n Electrolytes, BUN, glucose, ABGs, anion gap, osmol gap
CO2 or bicarb - does pt have anion gap?
n ECG, chest X-ray, abdominal X-ray
n Drug levels, Tox screens

Toxic alcohols - osmol gap
Arterial blood gas or venous blood gas (less painful)
Wide QRS or QTc is important
Body packer amy be seen in X- ray

Question 18

“Drug Screens”

Answer 18

n Typically 2 types
n Immunoassay screening test
n Quick, many limitations, risk of false positives
n UDS: The Urine Drug Screen (AKA the Useless
Drug Screen)
n Rarely change management. (So why do it?)
n Comprehensive Intensive (Call Tox Lab)
n Usually done with LC/MS or GC/MS
n Can takes days to weeks

Question 19

Urine drug screen: “Pee on a stick”

Answer 19

n Does not replace clinical judgment
n They are a single piece of information to consider
in the clinical picture
n Rarely make a clinical difference
n Differs from lab to lab
n Not all toxins screened
n Cross-sensitivity can be an issue

A drug screen cannot rule in poisoning.
At best, it can support a diagnosis

Question 20

Comprehensive Urine Drug Screens
(Using LC/MS)

Answer 20

n Labour intensive
n Lengthy to perform
n Used most often for academic or medicallegal purposes
n Rarely contribute to management of the
poisoned patient in the acute situation

Question 21

When to get a fancy Comprehensive
LC/MS test?

Answer 21

Suspicion of child abuse, homicide, sexual
assault
n Some patients with brain death (rule out
toxicologic cause for clinical picture)
n New Public Health Outbreak (Carfentanyl/
PMMA)
n Delirium/altered mental status
unexplained by other cause

Question 22

DRUG LEVELS

Answer 22

n Quantitative measurements
n Few substances where clinically relevant
n Limited by availability at each hospital
n Different labs have different capabilities
n If they CAN do level, it may have a different
sensitivity level than other labs

Question 23

Examples of Toxins with Clinically
Relevant Quantitative Levels

Answer 23

n Acetaminophen
n Salicylate
n Iron
n Digoxin
n Lithium
n Anticonvulsants
n Methanol
n Ethylene glycol
n Isopropyl alcohol
n Heavy metals
n Carbon monoxide